Levels of pain and different strengths of painkillers

Pain can be mild, moderate or severe. It can be treated using different strengths of painkiller, depending on your level of pain. To decide which type of painkiller is best, your doctor or nurse may use a tool called the analgesic ladder. The ladder shows each level of pain and the type of painkillers that are best to control it.

  • Mild pain, Step one includes non-opioid drugs for example paracetamol and anti-inflammatory drugs (Brufen®, Neurofen®).
  • Moderate pain, Step two includes weak opioid drugs for example dihydrocodeine (DF118 Forte®, DHC Continus®), codeine phosphate or tramadol.
  • Moderate to severe pain, Step three includes strong opioid drugs for example morphine, fentanyl and oxycodone.

Different painkillers do different things and are sometimes used in combination. For example, non-opioid painkillers are often used alongside weak or strong opioids. Other medicines, known as adjuvant drugs may also be used to control pain. Examples are bisphosphonates and steroids.

If you experience any side effects, tell your doctor or nurse. You should also talk to them before taking any other medicines.

Levels of pain control

Different types of painkillers are effective for mild, moderate or severe pain. This is explained in an analgesic ladder, which is a tool doctors and nurses often use to find the best medicines for your pain.
Examples of non-opioids, weak opioids, strong opioids and other medicines are explained below.
[INSERT Diagram showing levels of pain control. View a large version of the diagram showing levels of pain control.]

Managing pain during advanced cancer

Managing pain during advanced cancer

Oncologist Sarah Slater explains how painkillers help people with advanced cancer.

About our cancer information videos

Managing pain during advanced cancer

Oncologist Sarah Slater explains how painkillers help people with advanced cancer.

About our cancer information videos


How the analgesic ladder is used

If your pain is not controlled by a painkiller from step one on the analgesic ladder, your nurse or doctor will prescribe a painkiller from step two.

For example, if you’re taking a mild painkiller such as paracetamol but are still getting pain, your doctor should prescribe a weak opioid from step two. This may be a painkiller such as dihydrocodeine, codeine phosphate or tramadol. If the pain still isn’t controlled or it increases, your doctor could then prescribe a strong opioid from step three, such as morphine.

You don’t have to start with painkillers from the mild group – if you have moderate or severe pain when you first see your doctor, you can start by taking painkillers from step two or step three.

Often, non-opioid painkillers are used at the same time as weak or strong opioid painkillers, as they work in different ways.

For example, a strong painkiller such as morphine can be used with a mild painkiller such as paracetamol or ibuprofen.

At each step of the analgesic ladder, other medicines can also be used to control pain. These include bisphosphonates, steroids and drugs for nerve pain. Although they are not painkillers, they can be used for certain types of pain.

There is more information about how non-opioid, weak opioid and strong opioid drugs are given below.


Step one: Non-opioid drugs for mild pain

Mild pain is treated with painkillers such as paracetamol, and anti-inflammatory drugs.

Paracetamol can be used for most types of mild pain. It can be bought from a chemist or supermarket. It has few side effects, but it’s important not to take more than the recommended dose. Higher doses can damage the liver. Paracetamol does not reduce inflammation.

Anti-inflammatory drugs such as ibuprofen (Brufen®, Neurofen®) help reduce inflammation and swelling. They are good for treating pain in the skin, muscle or bone. Ibuprofen can be bought from a pharmacist or supermarket. Other anti-inflammatory medicines need to be prescribed by a doctor.

Check with your doctor or nurse before taking these types of medicines. They do not always work for everyone and may not mix well with other medicines. Anti-inflammatory drugs can cause indigestion and may irritate the lining of the stomach, so it’s important to take them after a meal or snack.

Your doctor may prescribe another medicine to help protect your stomach. If you’ve had previous problems with stomach ulcers, your doctor may advise you not to take anti-inflammatory drugs at all.

When taking these drugs, always check the recommended dose on the packet and never take a higher dose.

Remember that other medicines or tablets that you can buy from a pharmacy or supermarket may also contain paracetamol or anti-inflammatory drugs such as aspirin or ibuprofen. These should not be taken as well as other pain medicines unless advised by your doctor. Check with your pharmacist before buying any other medicines.


Step two: Weak opioid drugs for moderate pain

Moderate pain is treated with weak opioid drugs such as dihydrocodeine (DF118 Forte®, DHC Continus®), codeine phosphate or tramadol.

These are often combined with paracetamol in a single tablet (for example, co-codamol contains codeine and paracetamol, and co-dydramol contains dihydrocodeine and paracetamol). Combination painkillers have brand names such as Tylex®, Remedeine®, Solpadol®, Kapake® and Tramacet®. Most are only available on prescription from a doctor. There is a limit to the number of tablets that can be taken in one day. If your pain isn’t controlled, it’s important to let your doctor know so that you can be switched to stronger painkillers.

Some weak opioids may cause side effects such as constipation, nausea or drowsiness.


Step three: Strong opioid drugs for moderate to severe pain

Moderate to severe pain is treated with strong opioids, such as morphine, fentanyl and oxycodone. We have more information about types of strong opioids.

With this type of painkiller, it’s important for your doctor to find the most effective dose for you. Two people with the same type of cancer may need different doses of the same drug, even if they’re at the same stage of their illness. It’s common to start at a low dose and increase it gradually to a dose that controls your pain.

If your pain increases or decreases, the dose of your painkiller can be changed. You may only need a small increase in dose to get your pain under control again. But if your pain is bad, your doctors may increase the dose by a larger amount.

It can take a few days to adjust to taking a strong opioid painkiller.

Strong painkillers have side effects. If you have side effects, tell your doctor or nurse. A different type of strong painkiller may be better for you and not cause side effects. 

Other painkillers may be used with strong opioids. For example, paracetamol or anti-inflammatory drugs such as ibuprofen. If your doctor or specialist nurse suggests this, it is important to take these as well as your strong painkiller.